While disc problems cause back pain and are often responsible for sciatica (leg pain), ligaments that are strained or lax are the most common cause.
When you bend over the sacroiliac joints (SIJ) must loosen and release the pelvis to allow for the necessary movement. The only structures that hold these bones together are very strong ligaments. If one twists to pick something off the floor while they are bent forward, the SIJ can get caught at an awkward angle, causing severe and immediate pain and muscle spasm. Usually the pain passes in a few days as the SIJ can return to its usual position. Often, however, it stays misaligned and can cause ongoing, chronic back problems. After a while, the ligaments that hold the joints in place can become lax and overstretched, much as a rubberband that has been holding too many pencils. When this happens, one’s back can “go out” frequently or there can be a chronic ache that gets worse with sitting or standing, but better with walking a short distance or constantly changing positions.
When one has sciatica, they usually think that a disc pinching a nerve in the back causes it. The spinal nerves run from the spinal cord area down the legs and pressure at their origins can cause symptoms further down their length. This is called referred pain. While this is true, ligaments also refer pain to the buttock and leg pain in specific patterns that were worked out by Kelgren in the 1930′s. He took medical student “volunteers” and injected them with concentrated salt solution into specific ligaments. He then recorded exactly where they felt pain. We use these patterns today to help decide which ligaments are involved.
Ligaments are sensitive to pressure and tension. When they are strained or lax they send painful stimuli to the brain and one experiences pain or even a numb-like sensation called nulliness. When one changes positions or gets up to walk this ongoing stimulation is relieved and the pain goes away. When the physician examines a patient with this type of problem, she or he finds that the ligaments themselves are tender to touch.
The treatment is to correct the misalignment with manipulation performed by an osteopathic physician, chiropractor, physician, or physical therapist well trained in this type of work. There is often immediate relief of pain, although if the problems are longstanding it may take time for the ligaments to heal. Many research studies have shown the value of this type of intervention. I feel that if manipulation is going to work, it will help early and if there is no change after two or three treatments, something else, such as an injection of cortisone with lidocaine in the area of the painful ligaments needs to be done. Another important aspect of care is to maintain the corrected position with specific exercises. Nutritional supplements such as vitamin C, many of the B’s, and glucosamine sulfate are also important for helping the ligaments to heal. Following a low carbohydrate diet decreases insulin levels, allowing the cells to produce more anti-inflammatory prostaglandins.
Although these conservative measures should be tried first, it is very common for the ligaments to get too lax for them to be effective. If they fail to relieve the problem the next treatment is to induce a mild Inflammation in the ligaments by injecting a concentrated sugar and lidocaine solution onto the ligaments themselves. This effects healing that results in stronger and less sensitive ligaments that will not allow abnormal movement and are not as sensitive to pain. This is called Proliferative Therapy. A series of injections is given at intervals of one to two weeks. There are two double blind controlled research studies one in the Lancet (1987) and the other in The Journal of Spinal Disorders (1993) that show that this treatment is effective about 80 percent of the time.
Most physicians are not familiar with many of the concepts that I have outlined in this article. If you have suffered with chronic low back pain that has not responded to the usual treatment of exercise and medication, perhaps you explore some of them.